MOLINA HEALTHCARE OF MICHIGAN PRIOR AUTHORIZATION / PRE-SERVICE REVIEW GUIDE IMAGING CODES REQUIRING PRIOR AUTHORIZATION EFFECTIVE 1/1/2014

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1 70336 MRI MRI, temporomandibular joint(s) CT/CTA CT, head or brain; without contrast material CT/CTA CT, head or brain; with contrast material(s) CT/CTA CT, head or brain; without contrast material, followed by contrast material(s) and further sections CT/CTA CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material CT/CTA CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast CT/CTA CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; w/o contrast material, followed by contrast CT/CTA CT, maillofacial area; without contrast material CT/CTA CT, maillofacial area; with contrast material(s) CT/CTA CT, maillofacial area; without contrast material, followed by contrast material(s) and further sections CT/CTA CT, soft tissue neck; without contrast material CT/CTA CT, soft tissue neck; with contrast material(s) CT/CTA CT, soft tissue neck; without contrast material followed by contrast material(s) and further sections CT/CTA CT angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT/CTA CT angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRI MRI, temporomandibular joint(s) MRI MRI, orbit, face, and/or neck; with contrast material(s) MRI MRI, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, head; without contrast material(s) MRA MRA, head; with contrast material(s) MRA MRA, head; without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, neck; without contrast material(s) MRA MRA, neck; with contrast material(s) MRA MRA, neck; without contrast material(s), followed by contrast material(s) and further sequences MRI MRI, brain (including brain stem); without contrast material MRI MRI, brain (including brain stem); with contrast material(s) MRI MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences MRI MRI, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation MRI MRI, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing MRI MRI MRI MRI, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material MRI, brain (including brain stem and skull base), during open intracranial procedure; with contrast material(s) MRI, brain (including brain stem and skull base), during open intracranial procedure; without contrast material(s), followed by contrast material(s) and further sequences CT/CTA CT, thora; without contrast material CT/CTA CT, thora; with contrast material(s) CT/CTA CT, thora; without contrast material, followed by contrast material(s) and further sections CT/CTA CTA, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing MRI MRI, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) MRI MRI, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) MRI MRI, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, chest (ecluding myocardium), with or without contrast material(s) CT/CTA CT, cervical spine; without contrast material CT/CTA CT, cervical spine; with contrast material Molina Healthcare of Michigan, Inc. 1 of 5

2 72127 CT/CTA CT, cervical spine; without contrast material, followed by contrast material(s) and further sections CT/CTA CT, thoracic spine; without contrast material CT/CTA CT, thoracic spine; with contrast material CT/CTA CT, thoracic spine; without contrast material, followed by contrast material(s) and further sections CT/CTA CT, lumbar spine; without contrast material CT/CTA CT, lumbar spine; with contrast material CT/CTA CT, lumbar spine; without contrast material, followed by contrast material(s) and further sections MRI MRI, spinal canal and contents, cervical; without contrast material MRI MRI, spinal canal and contents, cervical; with contrast material(s) MRI MRI, spinal canal and contents, thoracic; without contrast material MRI MRI, spinal canal and contents, thoracic; with contrast material(s) MRI MRI, spinal canal and contents, lumbar; without contrast material MRI MRI, spinal canal and contents, lumbar; with contrast material(s) MRI MRI, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical MRI MRI, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic MRI MRI, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar MRA Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) CT/CTA CTA angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT/CTA CT, pelvis; without contrast material CT/CTA CT, pelvis; with contrast material(s) CT/CTA CT, pelvis; without contrast material, followed by contrast material(s) and further sections MRI MRI, pelvis; without contrast material(s) MRI MRI, pelvis; with contrast material(s) MRI MRI, pelvis; without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, pelvis, with or without contrast material(s) CT/CTA CT, upper etremity; without contrast material CT/CTA CT, upper etremity; with contrast material(s) CT/CTA CT, upper etremity; without contrast material, followed by contrast material(s) and further sections CT/CTA CTA angiography, upper etremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRI MRI, upper etremity, other than joint; without contrast material(s) MRI MRI, upper etremity, other than joint; with contrast material(s) MRI MRI, upper etremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences MRI MRI, any joint of upper etremity; without contrast material(s) MRI MRI, any joint of upper etremity; with contrast material(s) MRI MRI, any joint of upper etremity; without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, upper etremity, with or without contrast material(s) CT/CTA CT, lower etremity; without contrast material CT/CTA CT, lower etremity; with contrast material(s) CT/CTA CT, lower etremity; without contrast material, followed by contrast material(s) and further sections CT/CTA CTA angiography, lower etremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRI MRI, lower etremity other than joint; without contrast material(s) MRI MRI, lower etremity other than joint; with contrast material(s) MRI MRI, lower etremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences MRI MRI, any joint of lower etremity; without contrast material Molina Healthcare of Michigan, Inc. 2 of 5

3 73722 MRI MRI, any joint of lower etremity; with contrast material(s) MRI MRI, any joint of lower etremity; without contrast material(s), followed by contrast material(s) and further sequences MRA MRA, lower etremity, with or without contrast material(s) CT/CTA CT, abdomen; without contrast material CT/CTA CT, abdomen; with contrast material(s) CT/CTA CT, abdomen; without contrast material, followed by contrast material(s) and further sections CT/CTA CTA angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT/CTA CT, abdomen and pelvis; without contrast material CT/CTA CT, abdomen and pelvis; with contrast material(s) CT/CTA CT, abdomen and pelvis; without contrast material in 1 or both body regions, followed by contrast material(s) and further sections in 1 or both body regions MRI MRI, abdomen; without contrast material(s) MRI MRI, abdomen; with contrast material(s) MRI MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences MRA MRA, abdomen, with or without contrast material(s) CT/CTA CT colonography, diagnostic, including image postprocessing; without contrast material CT/CTA CT colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed CT/CTA CT colonography, screening, including image postprocessing MRI Cardiac MRI for morphology and function without contrast material; MRI Cardiac MRI for morphology and function without contrast material; with stress imaging MRI Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; MRI Cardiac MRI for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging MRI Cardiac MRI for velocity flow mapping (List separately in addition to code for primary procedure) CT/CTA CT, heart, without contrast material, with quantitative evaluation of coronary calcium CT/CTA and 3-D Imaging CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) CT/CTA and 3-D Imaging CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) CT/CTA and 3-D Imaging CTA, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT/CTA CTA, abdominal aorta and bilateral iliofemoral lower etremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT/CTA and 3-D Imaging 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation CT/CTA and 3-D Imaging 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation CT/CTA CT, limited or localized follow-up study CT/CTA Unlisted CT procedure (eg, diagnostic, interventional) MRI Unlisted magnetic resonance procedure (eg, diagnostic, interventional) MRI MRI, breast, without and/or with contrast material(s); unilateral MRI MRI, breast, without and/or with contrast material(s); bilateral CT/CTA CT, bone mineral density study, 1 or more sites; aial skeleton (eg, hips, pelvis, spine) MRI MRI, bone marrow blood supply SPECT Parathyroid planar imaging (including subtraction, when performed; with tomographic SPECT Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization SPECT Liver imaging (SPECT); SPECT Liver imaging (SPECT); with vascular flow Molina Healthcare of Michigan, Inc. 3 of 5

4 78320 SPECT Bone and/or joint imaging; tomographic (SPECT) Cardiac Nuclear Studies Determination of central c-v hemodynamics (non-imaging) (eg, EF with probe technique) with or without pharmacologic intervention or eercise, single or multiple determinations Cardiac Nuclear Studies Cardiac shunt detection SPECT SPECT Cardiac Nuclear Studies Cardiac Nuclear Studies Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, EF by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (eercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, EF by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (eercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, EF by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (eercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, EF by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (eercise or pharmacologic) and/or redistribution and/or rest reinjection PET Myocardial imaging, PET, metabolic evaluation Cardiac Nuclear Studies Myocardial imaging, infarct avid, planar; qualitative or quantitative Cardiac Nuclear Studies Myocardial imaging, infarct avid, planar; with EF by first pass technique SPECT Cardiac Nuclear Studies Cardiac Nuclear Studies Cardiac Nuclear Studies Cardiac Nuclear Studies Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (eercise and/or pharmacologic), wall motion study plus EF, with or without additional quantitative processing Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus EF, at rest and stress (eercise and/or pharmacologic), with or without additional quantification Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (eercise and/or pharmacologic), wall motion study plus EF, with or without quantification Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (eercise and/or pharmacologic), wall motion study plus EF, with or without quantification PET Myocardial imaging, PET, perfusion; single study at rest or stress PET Myocardial imaging, PET, perfusion; multiple studies at rest and/or stress SPECT Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus EF, with or without quantitative processing Cardiac Nuclear Studies Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular EF by first pass technique SPECT Brain imaging, tomographic (SPECT) PET Brain imaging, PET; metabolic evaluation PET Brain imaging, PET; perfusion evaluation SPECT Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) SPECT Kidney imaging morphology; tomographic (SPECT) SPECT Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) SPECT Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) PET PET imaging; limited area (eg, chest, head/neck) PET PET imaging; skull base to mid-thigh PET PET imaging; whole body PET PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; limited area PET PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh PET PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body fmri Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report 0126T IMT Testing Common carotid intima-media thickness (IMT) study Molina Healthcare of Michigan, Inc. 4 of 5

5 G0288 CT/CTA Reconstruction, CTA angiography of aorta for surgical planning for vascular surgery S8042 MRI MRI, low-field Not Covered by Not Covered by S8092 CT Electron beam computed tomography (also known as ultrafast CT, cine CT) Not Covered by Not Covered by Molina Healthcare of Michigan, Inc. 5 of 5

screening; including image post processing CT, heart; without contrast material; with Requires authorization

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